MEDICARE: MRS. JOBETH ROSS MCELHANON RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	642	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5X042	OTHER	AR	MNT PROVIDER

General Provider Information

NPI Number	:	1609810282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOBETH ROSS MCELHANON RD, LD

Provider Business Mailing Address
First Line	:	6412 CANTRELL RD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72207-4217
Country	:	US
Telephone Number	:	501-202-2117
Fax Number	:	501-202-7191

Provider Business Practice Location Address
First Line	:	9601 INTERSTATE EXIT 7
Second Line	:	BAPTIST HEALTH MEDICAL CENTER-LITTLE ROCK
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-7299
Country	:	US
Telephone Number	:	501-202-2117
Fax Number	:	501-202-7191

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	07/08/2007

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